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HEALTH HISTORY FORM - CHILD Please Print Patient s Last name First Middle Today s date / Birth date HRN ALLERGIES AND ANY DRUG ALLERGIES LIST ANY PRESCRIPTION DRUGS YOU TAKE PLEASE ANSWER THE FOLLOWING QUESTIONS ABOUT YOUR CHILDS HISTORY YES N0 Were there any complications during pregnancy Was the pregnancy full-term 9 months or 40 weeks Did the child go home with mother Does the child have any birth defects Has the child s growth and development been normal Are the child s immunizations...
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What is health history form?
The health history form is a document that collects information about a person's medical background, including past illnesses, surgeries, medications, and family medical history.
Who is required to file health history form?
Anyone seeking medical treatment or care at a healthcare facility may be required to fill out a health history form.
How to fill out health history form?
To fill out a health history form, one must provide accurate and detailed information about their medical history, including any current medications, allergies, and past surgeries or illnesses.
What is the purpose of health history form?
The purpose of a health history form is to help healthcare providers better understand a patient's medical background, which can assist in providing appropriate treatment and care.
What information must be reported on health history form?
Information such as past illnesses, surgeries, medications, allergies, and family medical history must be reported on a health history form.
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